The use of pacifiers (dummies or soothers) for infants is prevalent. Rare episodes of an adverse consequence must be taken seriously. We report a case of aspiration of a pacifier by a 6-month-old baby. Nine similar cases were found in the literature since 1966. The details of these cases are outlined and changes to flange design proposed ahead of a new European Union Standard document.
Conclusion: Pacifier ventilation holes are essential, flanges should have a minimum horizontal and vertical diameter of 43 mm. Rings should be attached to the flange to facilitate removal if aspirated.